Documente Academic
Documente Profesional
Documente Cultură
Facilitators:
Hestbaek L, The Natural Course of Low Back Pain and Early Identification
of High-Risk Populations. PhD Thesis. Odense, Denmark: University of
Southern Denmark, 2003.
The 10% of patients with LBP
who go on to have chronic
LBP and disability are
responsible for 80% of the
costs associated with this
condition
Differentialdiagnosis
Medical-surgical management
Location of pain
Intermittent, constant, episodic
Aggravating and easing factors
Effect of coughing, sneezing, and straining
Range of motion impairments (also locking and
crepitus)
Sensory abnormalities
Motor deficits
Inflammatory symptoms: redness, swelling,
increased temperature
Cauda equina syndrome
Zygapophyseal Joint Pain Syndrome
Lumbar Radiculopathy
Myofascial Pain Syndrome
Myofascial Pain Syndrome
Myofascial Pain Syndrome
Visceral Referral: Angiotomes
Visceral Referral: Organs
Mechanical versus Non-Mechanical
Deyo R, et al. What can the history and physical examination tell us
about low back pain? JAMA 1992;268:760-765.
Back Pain and Pathology
Visceral disease:
Retroperitoneal and pelvic region or the
gastrointestinal system
Vascular disease:
Abdominal aortic aneurysm
Hematological disease:
Hemoglobinopathies and myelofibrosis
Trauma:
Fracture, fatigue fracture, insufficiency
fracture
Metabolic and endocrine disease:
Osteoporosis, osteomalacia, Paget
disease, and diabetes (diabetic
radiculopathy)
Infectious disease:
Diskitis and osteomyelitis
Inflammatory disease:
Spondylarthropathies
Neoplastic disease:
Osteoid osteoma, multiple myeloma,
metastases
Huijbregts PA. HSC 11.2.4. Lumbopelvic region: Aging, disease,
examination, diagnosis, and treatment. In: Wadsworth C. HSC 11.2.
Current Concepts of Orthopaedic Physical Therapy. LaCrosse, WI:
Orthopaedic Section APTA, 2001.
Yellow Flags: Depression
Random population-based survey
Multivariate
analysis excluded
confounding variables.
Independent relationship between
depressive symptoms and onset of
neck or back pain episode.
Comparing lowest quartile of
depression scores to highest quartile.
Adjusted risk ratio most depressed
3.97
Carroll LJ, et al. Depression as a risk factor for onset of an episode
of troublesome neck and low back pain. Pain 2004;107:134-139.
Depression Screening
During the past month have you often been
bothered by feeling down, depressed, or
hopeless?
During the last month have you often been
bothered by little interest or pleasure in doing
things?
Sensitivity 97%; specificity 67%
Severe leg pain (7-10 pain rating): odds ratio (OR) 1.92
Fransen M, el al. Risk factors associated with the transition from acute to
chronic occupational back pain. Spine 2002;27:92-98.
Prospective cohort study to determine clinical
prediction rule for return-to-work status at 2 years
for 1,007 patients with LBP
Timeline
Mechanism of injury
Management of complaint and effect of
various management strategies
Diagnostic tests done…
Medical History
Previous medical history
Family history
Medication use
Imaging and lab test findings
Social History
Occupation
Leisure time activities
Environment/social role
Open versus Closed Questions?
Anything else I forgot to ask that might be
relevant or related to your current
complaint?
Limit open question but give the patient a
chance to have his or her say…
Physical Examination
Observation
Active range of motion testing
Neuroconductive testing including straight-
leg raise
Special tests
Active Range of Motion
Testing
Test cluster 1
Hip pain
Hip IR rotation ROM < 15 degrees
Hip flexion ROM < 115 degrees
Hip Osteoarthritis
Mens JMA, Vleeming A, Snijders CJ, Stam HJ, Ginai AZ. The active
straight leg raise test and mobility of the pelvic joints. Eur Spine J
1999;8:468-473.
Segmental tests
Motion and provocation tests
Accessory motion tests: prone posterior-
to-anterior pressure
Physiological motion tests: Flexion,
extension, sidebending, rotation
Stability: Translational mobility
Accessory Motion Tests
Physiological Motion Tests
Segmental Motion Tests
Combination of accessory and physiological
manual tests
Compared to lumbar spinal block
Prospective study component
Segmental dysfunction based on both mobility
and pain findings
Sensitivity 95%
Specificity 100%
1Phillips DR, Twomey LT. A comparison of manual diagnosis with a
diagnosis established by a uni-level lumbar spinal block procedure.
Man Ther 1996;2:82-87.
Palpation
Diagnosis myofascial trigger points
Essential criteria include:
Taut band palpable (where muscle is
accessible)
Exquisite spot tenderness of a nodule in a taut
band
Patient recognition of current pain complaint by
pressure on the tender nodule (identifies an
active trigger point)
Painful limit to full stretch range of motion
Palpation
Confirmatory observations are:
Visual or tactile identification of a local twitch
response
Imaging of an local twitch response induced by
needle penetration of tender nodule
Pain or altered sensation (in the distribution
expected from a trigger point in that muscle) on
compression of tender nodule
Electromyographic demonstration of
spontaneous electrical activity characteristic of
active loci in the tender nodule of a taut band
Simons DG, Travell JG, Simons LS. Travell and Simons' Myofascial Pain and
Dysfunction: The Trigger Point Manual. 2nd ed. Vol. 1. Baltimore, MD:
Williams & Wilkins, 1999.
Imaging and Lab Tests
Imaging not required when red flags are absent
High number of false positives of CT and MRI
Imaging needs to be interpreted in light of
findings of clinical examination
Lab tests?
Management
Medical management
Surgical management
Other specialist referral
Physiotherapy: Evaluation and diagnosis,
education, exercise, manual therapy and
massage, modalities, acupuncture and dry
needling, orthotics/bracing/taping,
ergonomic advice and adaptations
Other
LBP Myths
“Randomized controlled trials, studies into
diagnostic accuracy, systemic reviews,
and meta-analysis with provide the answer
to all our diagnostic and management
dilemmas!”
Anybody for exercise?
Systematic review on the use of exercise therapy for
acute and chronic LBP:
No indication that specific exercises are effective for
treatment of acute LBP.
Conflicting evidence on the effectiveness of exercise
therapy compared with inactive treatments for chronic
LBP.
Exercise therapy was more effective than usual care
by the general practitioner and just as effective as
conventional PT for chronic LBP.
Radicular symptoms.
Symptoms did not improve with any movement
tests.
Symptoms worsened with most movement tests.
Fritz JM, Brennan GP, Leaman H. Does the evidence for spinal manipulation
translate into better outcomes in routine clinical care for patients with occupational
low back pain? A case-control study. Spine J 2006;6:289-295.
Common-Sense Summary